TO:

Agency WPV Coordinators

FROM:

Donna Hoskins-Helm, Workplace Support Services Division

DATE:

June 19, 2009

RE:

Workplace Violence Incident Reporting Guide

In an effort to improve reporting capabilities, the Office of Administration has

refined the workplace violence reporting system. Your agency should continue to
use the assigned user name and password in order to access the database.
When entering data into the online report system, data fields identified with a red
asterisk (*) are required fields and must be completed in order for the report to be
accepted by the system. Please obtain the required information before attempting
to enter a report.
Because not all information may be available or accurate at the time the initial
report is transmitted, you may create a password to edit or update the existing
record at a later date.
To support a unified approach to data entry, an explanation of each data field is
provided below. For questions on completing and transmitting workplace violence
reports, please contact Susan Moravetz, Office of Administration, Workplace
Support Services Division at (717) 787-8575.

Attachment

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page 2 of 16

Guidelines for Completing the Workplace Violence Online Incident Report

During the pre-population stage, please identify any perpetrators and victims who
are commonwealth employees by their employee number. The information entered
at this stage will populate to the corresponding data fields. Be sure the persons
identified as Perpetrator 1, 2, and 3; Victim 1, 2, and 3; and Investigator 1, 2, and
3 are used consistently throughout the report. (Refer to screen print #1.) In the
event an incident involves more than three perpetrators or victims, please contact
the Workplace Support Services Division at (717) 787-8575.
Perpetrator 1 Employee Number
This field is required only if Perpetrator 1 was a commonwealth employee. Leave
blank if not applicable.
Perpetrator 2 Employee Number
This field is required only if Perpetrator 2 was a commonwealth employee. Leave
blank if not applicable.
Perpetrator 3 Employee Number
This field is required only if Perpetrator 3 was a commonwealth employee. Leave
blank if not applicable.
Victim 1 Employee Number
This field is required only if Victim 1 was a commonwealth employee. Leave
blank if not applicable.
Victim 2 Employee Number
This field is required only if Victim 2 was a commonwealth employee. Leave
blank if not applicable.
Victim 3 Employee Number
This field is required only if Victim 3 was a commonwealth employee. Leave
blank if not applicable.

Office of Administration | 207 Finance Building | Harrisburg, PA 17120 | 717.787.9945 | www.oa.state.pa.us

page 3 of 16

Screen print #1.

After clicking the submit button, you will be directed to the body of the form
where the following information will need to be entered.
1. Agency Name: required field (Screen print #2.)
Use the drop down menu to select the name of the agency in which the incident
took place, even if it did not involve employees of that agency. If the incident
took place at a location that is not commonwealth owned or leased property,
enter the agency of the involved employees. The agency selected should match
the agency of the employee conducting the incident investigation.
2. Street Address: required field (Screen print #2.)
Enter the street address of the location where the incident occurred. Please do
not use post office box numbers. Include the building name, floor number, and
room number if applicable.
3. Municipality: required field (Screen print #2.)
Enter the name of the city or town where the incident occurred.
4. County: required field (Screen print #2.)
Enter the county name where the incident occurred.
5. Date of Incident: required field (Screen print #2.)
Enter the date that the incident occurred using mm/dd/yyyy format.
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6. Time of Incident: required field (Screen print #2.)

Enter the time that the incident occurred using military time.
7. Day of the Week: required field (Screen print #2.)
Use the drop down menu to select the day of the week that the incident
occurred.

Screen print #2.

8. Location of Incident: required field (Screen print #3.)
Use the drop down menu to select the location where the incident occurred.
Should a single incident involve more than one location, please select a primary
and secondary location. Then use the other text box to identify where the
incident first began and list additional involved locations.
9. Type of Violence: required field (Screen print #3.)
Use the drop down menu to select the specific type of incident that occurred.
Should a single incident involve more than one specific type of violence, please
select a Choice 1 and a Choice 2. Then use the other text box to identify
additional acts or specify a type of act not available in the drop down list.

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page 5 of 16

10. Type of Personal Threat (Screen print #3.)

This field is required only if Personal Threat is selected for Type of Violence.
Use the drop down menu to select the specific type of threat. Use the other
text box to specify a type of threat not available in the drop down list.
11. Type of Bomb Threat (Screen print #3.)
This field is required only if Bomb Threat is selected for Act of Violence. Use
the drop down menu to select the specific manner in which the threat was
made. Use the other text box to specify a manner not available in the drop
down list.
12. Weapon Involved: required field (Screen print #3.)
Select Yes or No as appropriate.
13. Type of Weapon (Screen print #3.)
This field is required only if Yes was selected in the previous question. Use the
drop down menu to select the specific type of weapon used. Use the other text
box to specify a type of weapon not available in the drop down list.

Screen print #3.

14. Number of Perpetrators (Screen print #4.)
Use the text box to specify the total number of perpetrators involved.
15. Number of Females (Screen print #4.)
Use the text box to specify the number of female perpetrators involved.
Office of Administration | 207 Finance Building | Harrisburg, PA 17120 | 717.787.9945 | www.oa.state.pa.us

page 6 of 16

16. Number of Males (Screen print #4.)

Use the text box to specify the number of male perpetrators involved.
17. Perpetrator(s) Information (Screen print #4.)
Identity: required field
Use the drop down menu to select the identity of the perpetrator involved. The
person identified as Perpetrator 1, 2, and 3 should be used consistently
throughout the report. Leave Perpetrator 2 and 3 blank if not applicable.
Gender
Select Female or Male as appropriate
Name
Use the text box to identify Perpetrator. If the employee number was entered
during the pre-population stage, it should be completed for you. Leave blank if
not applicable.
Employee Number
This field is required only if Perpetrator was a commonwealth employee. If the
employee number was entered during the pre-population stage, it should be
completed for you. Leave blank if not applicable.
Job Code and Title
This field is required only if Perpetrator was a commonwealth employee. If the
employee number was entered during the pre-population stage, it should be
completed for you. Leave blank if not applicable.
Org ID and Name
This field is required only if Perpetrator was a commonwealth employee. If the
employee number was entered during the pre-population stage, it should be
completed for you. Leave blank if not applicable.
Supervisor or Management Level Employee
This field is required only if Perpetrator was a commonwealth employee. Select
Yes or No as appropriate. Leave blank if not applicable.

Office of Administration | 207 Finance Building | Harrisburg, PA 17120 | 717.787.9945 | www.oa.state.pa.us

page 7 of 16

Screen print #4.

18. Number of Victims: required field (Screen print #5.)
Use the text box to specify the total number of victims involved.
19. Number of Females: required field (Screen print #5.)
Use the text box to specify the number of female victims involved.
20. Number of Males: required field (Screen print #5.)
Use the text box to specify the number of male victims involved.
21. Victim Information (Screen print #5.)
Identity: required field
Use the drop down menu to select the identity of the victim involved. The person
identified as Victim 1, 2, and 3 should be used consistently throughout the
report. Leave Victim 2 and 3 blank if not applicable.
Gender
Select Female or Male as appropriate
Name
Use the text box to identify Victim. If the employee number was entered during
the pre-population stage, it should be completed for you. Leave blank if not
applicable.

Office of Administration | 207 Finance Building | Harrisburg, PA 17120 | 717.787.9945 | www.oa.state.pa.us

page 8 of 16

Employee Number
This field is required only if Victim was a commonwealth employee. If the
employee number was entered during the pre-population stage, it should be
completed for you. Leave blank if not applicable.
Job Code and Title
This field is required only if Victim was a commonwealth employee. If the
employee number was entered during the pre-population stage, it should be
completed for you. Leave blank if not applicable.
Org ID and Name
This field is required only if Victim was a commonwealth employee. If the
employee number was entered during the pre-population stage, it should be
completed for you. Leave blank if not applicable.
Supervisor or Management Level Employee
This field is required only if Victim was a commonwealth employee. Select Yes
or No as appropriate. Leave blank if not applicable.

Screen print #5.

22. Witnesses: required field (Screen print #6.)
Select Yes or No as appropriate to indicate if witnesses were present or not.
Maintain a list of names and phone numbers separate from this report.

Office of Administration | 207 Finance Building | Harrisburg, PA 17120 | 717.787.9945 | www.oa.state.pa.us

page 9 of 16

23. Incident Involved Death: required field (Screen print #6.)

Select Yes or No as appropriate to indicate if the incident resulted in any
deaths.
24. Incident Involved Injury: required field (Screen print #6.)
Select Yes or No as appropriate to indicate if there were any injuries that
required medical attention.

Screen print #6.

25. Describe Injuries Suffered (Screen print #7.)
This field is required only if Yes was selected for question 24, Incident
Involved Injury. Use the text box to describe the nature of the injuries
sustained and what medical action was taken.
26. Work-Related Injury Report or W/C Claim Filed (Screen print #7.)
This field is required only if Yes was selected for question 24, Incident
Involved Injury. Use the drop down menu to select the appropriate response.
27. Description of Incident: required field (Screen print #7.)
Use the text box to describe the nature of the incident and include other
relevant information. If there are more than three victims, identify here.
28. Law Enforcement Officials Contacted (Screen print #7.)
Select Yes or No as appropriate.
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page 10 of 16

Screen print #7.

29. Responding Law Enforcement Agency (Screen print #8.)
This field is required only if Yes was selected for question 28, Law
Enforcement Officials Contacted. Use the drop down menu to select the type of
agency. Use the other text box to specify an agency not available in the drop
down list.
30. Was Anyone Arrested (Screen print #8.)
Select Yes or No as appropriate.
31. SEAP Contacted by Agency: required field (Screen print #8.)
Use the drop down menu to select the appropriate response.
32. Safety Plan Implemented (Screen print #8.)
Select Yes or No as appropriate.
33. Safety Plan Details (Screen print #8.)
Use the text box to describe the safety plan. Leave blank if not applicable.
34. Other Relevant Data (Screen print #8.)
Use the text box to describe any additional factors that are related to the
incident such as media coverage, structural damage, or impact on agency
services. Leave blank if not applicable.

Office of Administration | 207 Finance Building | Harrisburg, PA 17120 | 717.787.9945 | www.oa.state.pa.us

page 11 of 16

35. Completing On-Site Report Completed By (Screen print #8.)

a. Name: required field
Use the text box to identify the person who prepared the original report at
the incident location. In most cases, this will not be the same person as
the individual who is inputting the information into the online report.
b. Job Title
Use the text box to identify the job title of the person who prepared the
original report at the incident location. In most cases, this will not be the
same person as the individual who is inputting the information into the
online report.
c. Phone Number: required field
Use the text box to list the phone number using a ###-###-####
format.

Screen print #8.

36. Date of On-site Report (Screen print #9.)
Use the text box to enter the date the initial report was completed using
mm/dd/yyyy format. This date may be different from the date the information is
entered into the online database system but should match the date of the
incident.

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page 12 of 16

37. Your Personal Info (Screen print #9.)

a. Your Name: required field
b. Your Job Title
Use the text box to identify your job title.
c. Your Phone Number: required field
Use the text box to list your phone number using a ###-###-####
format.
At this point in the form, you have the opportunity to create a password and save
and close your progress. This is also the point in the form that you will indicate that
the status of the form is Pending, meaning there is more information to be
gathered to complete it, or Complete meaning you have the information to
complete the rest of the form. If you submit a form as Pending, you will need to
use the password and access the form and update it to reflect additional
information as it becomes available and to confirm the outcome of the
investigation. In addition, you can generate a paper summary of the individual
record for your own internal use.
38. Investigation Confirmed that Workplace Violence Occurred:
required field when the status of the form is selected complete.
(Screen print #9.)
Select Yes or No as appropriate.
39. Investigation Confirmed that Inappropriate Workplace Behavior
Occurred: required field when the status of the form is selected
complete. (Screen print #9.)
Select Yes or No as appropriate.
If Perpetrator 1 was a commonwealth employee, complete questions 40 through 44.
Leave blank if not applicable.
40. Discipline Applied (Screen print #9.)
Select Yes or No as appropriate.
41. If Yes, What Level Applied (Screen print #9.)
This field is required only if Yes was selected in question 40, Discipline
Applied. Use the drop down menu to select the type of discipline.

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Screen print #9.

42. Final Warning Given (Screen print #10.)
Select Yes or No as appropriate to indicate if a final warning was issued in
conjunction with discipline.
43. Grieved or Appealed (Screen print #10.)
Select Yes or No as appropriate to indicate if the employee grieved or
appealed the discipline.
44. Discipline Sustained as Issued (Screen print #10.)
Select Yes or No as appropriate to indicate if the discipline was sustained in
whole. If the discipline was sustained in part, this answer should be marked as
No.
45. Discipline Modified (Screen print #10.)
This field is required only if No was selected for question 44, Discipline
Sustained as Issued. Use the text box to describe in what manner the discipline
was modified.

Office of Administration | 207 Finance Building | Harrisburg, PA 17120 | 717.787.9945 | www.oa.state.pa.us

page 14 of 16

Screen print #10.

If Perpetrator 2 was a commonwealth employee, complete questions 46 through 50
in the same manner as above. Leave blank if not applicable.
If Perpetrator 3 was a commonwealth employee, complete questions 52 through 56
in the same manner as above. Leave blank if not applicable.
If Yes was selected for question 28, Law Enforcement Officials Contacted,
complete questions 58 and 59. Leave blank if not applicable.

Office of Administration | 207 Finance Building | Harrisburg, PA 17120 | 717.787.9945 | www.oa.state.pa.us

page 15 of 16

58.Result of Police Investigation (Screen print #11.)

This field is required only if Yes was selected for question 28, Law
Enforcement Officials Contacted.
59.Were Charges Pressed (Screen print #11.)
Select Yes or No as appropriate.

Screen print #11.

60.Other Agency Actions (Screen print #12.)
Use the text box to describe any other actions taken by the agency not already
explained.
61.Date Investigation Completed (Screen print #12.)
Use the text box to enter the date the investigation was completed using
mm/dd/yyyy format. This date may be several months after the initial data was
entered into the online database system.
62.Person(s) Completing WPV Incident Investigation
print #12.)

(Screen

a. Name: required if form status is Complete

Use the text boxes to identify the employees who conducted the
investigation. The person identified as Investigator 1, 2, and 3 should be
used consistently. If more than three people were involved, additional
names can be documented in question 60, Other Agency Actions.

Office of Administration | 207 Finance Building | Harrisburg, PA 17120 | 717.787.9945 | www.oa.state.pa.us

page 16 of 16

b. Job Title
Use the text boxes to identify the job titles of the employees listed above.
Ensure the person identified as Investigator 1, 2, and 3 is used
consistently.
Leave Investigator 2 and 3 blank if not applicable.

Screen print #12.

For questions on completing and transmitting workplace violence reports, please
contact Susan Moravetz, Office of Administration, Workplace Support Services
Division at (717) 787-8575.

Office of Administration | 207 Finance Building | Harrisburg, PA 17120 | 717.787.9945 | www.oa.state.pa.us